Insurance and Billing FAQs

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Thank you choosing for Children’s National Health System for your child’s healthcare needs. We understand navigating through financial matters associated with healthcare can be confusing. The following is a list of frequently asked questions related to billing and insurance.

Questions to ask your insurance provider

Does my surgery/hospital stay need preauthorization?

In most cases, preauthorization is a requirement for services listed in your health insurance policy. Please review your health insurance policy for details. To get your surgery or hospital stay preauthorized, your health insurance policy should give you the steps for preauthorization. Your health insurance provider will notify you if the procedure or hospital stay is approved or denied. If you are being hospitalized, the specific number of days approved will usually also be provided.

What if you have a pre-existing condition?

Insurers can impose only a 12-month waiting period for any preexisting condition that has been diagnosed or treated within the preceding six months. As long as you have maintained continuous coverage without a break of more than 63 days, your prior health insurance coverage will be credited toward the preexisting condition exclusion period.

If you have had group health coverage for at least one year and you change jobs and health plans, your new plan can't impose another preexisting condition exclusion period. If you have never been covered by an employer's group plan and you start a new job that offers such a plan, you may be subject to a 12-month preexisting condition waiting period. Federal law also makes it easier for you to get individual insurance under certain situations. You may, however, have to pay a higher premium for individual insurance if you have a preexisting condition. If you have not had coverage previously and you are unable to get insurance on your own, you should check with your state insurance commissioner to see if your state has a high-risk pool.

What types of services are generally covered by a group health insurance plan?

Generally, a comprehensive plan will include the full range of medical services. These may include:

Professional services of doctors of medicine and osteopathy and other recognized medical practitioners

Hospital charges for semiprivate room and board and other necessary services and supplies

Surgical charges

Services of registered nurses

Home health care

Physical therapy

Anesthetics and their administration

X-rays and other diagnostic laboratory procedures

Oxygen and other gases and their administration

Blood transfusions, including the cost of bloom when charged

Drugs and medicines requiring a prescription

Specified ambulance services

Rental of durable mechanical equipment required for therapeutic use

Artificial limbs and other prosthetic appliances, except replacement of such appliances

Casts, splints, trusses, braces, and crutches

Health insurance terms keywords

What is coinsurance?

Co-insurance requires the insured to share in the cost of medical care. Under an 80/20 coinsurance provision, the medical expense plan pays 80 percent of eligible medical charges above any deductible. The insured is required to pay the remaining 20 percent. Other coinsurance arrangements, i.e., 70/30 or 90/10, are sometimes used. In the event of large or catastrophic medical expenses, an insured might suffer severe financial hardship due to the operation of the coinsurance clause. To compensate for this possibility, many major medical expense plans contain a coinsurance cap or limit. This provision places a limit on the insured's out-of-pocket costs in a given year. The size of the coinsurance cap generally ranges from $2,000 to $3,000, depending on the plan, although limits as low as $1,000 are sometimes used. Once the coinsurance cap has been reached, all eligible expenses above this amount are paid in full, up to the plan's overall limit of coverage.

What is a deductible?

Most PPO plans require participants to pay the full cost of medical services until they reach a certain dollar figure (for example $1,000) before your insurance will make any payments. This is called the deductible. Once you have spent the amount of the deductible in any given calendar year, the health plan coverage kicks in.

What is authorization/preauthorization?

Authorization/preauthorization is when the insurance company is notified in advance of a surgery or hospital stay and is a required notification for most policies for the insurance company to pay for the care. The requirements can differ from policy to policy but the purpose of preauthorization is to notify the insurer or representative so they can determine if a hospitalization or surgery is medically necessary and how many days of hospitalization are authorized. If preauthorization is not obtained, the insurer will deny coverage for an otherwise covered service.

What are carve outs?

Carve-outs are the separation of a medical service (or a group of services) from the basic set of benefits in some way. In many instances, a different provider will provide the service (e.e., behavioral health is a common carve-out service). The carve-out is typically done through separate contracting or sub-contracting for services to the special population. Increasingly, oncology and cardiac services are being carved out. Many HMOs and insurance companies adopt this strategy because they do not have in-house expertise related to the service "carved out." This process may or may not seem transparent to the subscriber, but it often means that separate UR and pre-certification entities are involved as well as different payers and providers. Carve-outs are also known as sub-contractors.

What are definitions, benefits, limitations, and exclusions?

Every health insurance policy or health plan agreement or evidence of coverage is divided into different sections. For instance, a section may identify “benefits” as including services by a physician or surgeon, hospital services, nursing services, medical equipment and the like. This section, in effect, gives a broad outline or index of the benefits covered by the insurance or plan. Sometimes within the same section, but also sometimes in a separate section, there are specific “definitions” of benefits or related terms. For instance, the term “physical therapy” may be defined as “medically necessary therapy ordered by a physician and provided by a registered physical therapist.” The benefit section may list physical therapy as a benefit, as an example, by identifying it as “acute physical therapy.” The term “acute” then may be defined in the policy as being only for a period of 60 days following injury or onset of illness. Then in the “limitations” section of the policy there may be a further qualification of acute physical therapy as only being authorized if it is anticipated that the therapy would result in substantial improvement of the condition within 60 days, or there may be a statement that the therapy is limited to a total dollar amount of charge, such as $500 or $1,000. Further, in the separate “exclusions” section there might be a statement that specifically says that any physical therapy beyond 60 days would be excluded or any physical therapy that would not result in substantial improvement of a condition within 60 days is not a covered benefit.

What is a co-payment?

A payment made by the patient or individual who has health insurance, usually at the time a service is received, to offset some of the cost of care. Co-payments are a common feature of HMOs and PPOs. Co-payment size may vary depending on the service, generally with lower co-payments required for physician office visits and higher payments for emergency room visits and sometimes other hospital care. The co-payment amount is usually determined by the employer so as to ensure the patient has some financial responsibility in their overall care.

What is an HMO?

An HMO (Health Maintenance Organization) is a plan product in which members must access the services of participating doctors, hospitals, and clinics in order to have their care covered by their insurance plan. Members typically have full coverage when they stay within their network of providers but no coverage if they choose care out of network. Members may have co-payments but usually do not have deductibles or co-payments.

Point-of-Service Plan or Point-of-Service Option (POS)

A product that offers the option to receive a service from a participating or a nonparticipating provider. Generally the level of coverage is reduced for services associated with the use of non-participating providers. Subscribers can select between different delivery systems (i.e., HMO, PPO and fee-for-service) when in need of healthcare services and at the time of accessing the services, rather than making the selection at time of open enrollment at place of employment. The costs associated with receiving care from the "in network" or contracted providers are less than when care is rendered by non-contracting providers. This is a method of influencing patients to use network providers without restricting their freedom of choice too severely.

What is a PPO?

In a PPO (Preferred Provider Organization), the plan contracts with physicians and hospitals to provide services at reduced cost. If you use these in-network medical providers, the plan pays most of the cost of treatment but members have more out of pocket costs (deductibles and co-insurance) than an HMO. Participants can use out-of-network health care providers, but must pay even higher portions of the cost of care (deductibles and co-insurance).

What is PSV?

Pediatric Specialists of Virginia (PSV) is a joint venture with Children’s National and Inova, two highly regarded and trusted medical centers, to provide world-class care for children and families. Through this physician group practice, Children’s National’s talented and nationally recognized teams will provide specialty services in shared settings, combining clinical strengths from both organizations and to make specialty care more convenient for families in northern Virginia and across the region. It offers pediatric Gastroenterology, Nephrology, Genetics, Hematology/Oncology, and Orthopedics through this collaboration at three locations in the Fairfax, Va., area. If opting to use PSV, confirm with your insurance carrier whether your plan participates with this entity since it does not necessarily accept all the same insurances as Children’s National and Inova.

What is a benefit package?

A benefit package is an aggregate of services specifically defined by an insurance policy or HMO that can be provided to patients, or the services a payer offers to a group or individual. The package will specify include cost, limitation on the amounts of services, and annual or lifetime spending limits.

Questions to ask the hospital

Why was my account placed with a collection agency before the hospital sent me a bill?

The hospital uses outside agencies to assist with our billing and follow up after statements are sent to you. If we do not receive payments, these agencies help us collect the outstanding balance. The most common reason you may not have received a bill prior to placement with collection agency is that we do not have a valid address for you. You can update your address by calling our Customer Service Department at 301-572-3542 or toll free at 800-787-0021.

What date of service does this bill cover

The first statement you receive for both hospital and physician services indicates the date of service. The physician statements will not repeat the date of service as these statements are cumulative – they carry the balance forward for all services previously billed and only new services will reference the date of service. The hospital service will continue to reference the date of service associated with each account.

Why do I receive two bills for each date of service?

Normally, your child will receive both professional (physician) and hospital (laboratory, X-ray, medication, etc) services. Insurance companies require that these services be billed on different forms. Our computer systems currently keep these charges separated, and as a result you will receive two bills for each date of service. The physician bill/statement is purple (cumulative for all services) and the hospital bill is green or blue (separate account for each service). Please review our billing process for more information.

If I have a question about my bill, who can I contact?

Our Customer Service team is available Monday-Friday, 9:00 am to 4:00 pm EST at 301-572-3542 or toll free at 800-787-0021 or e-mail bearbill@childrensnational.org.

Why was my bill sent to the wrong insurance

Each time your child is registered at Children’s, we ask that you review your information for accuracy. Changes should be noted on the face sheet. Our staff will update this information on your account and bill the charges to the updated plan. If the information on the bill you receive is incorrect, please contact Customer Service, Monday - Friday, 9:00 am to 4:00 pm EST at 301-572-3542 or toll free at 800-787-0021.

What if I cannot pay my bill in full at the time of service?

Our financial counselors will work with you to set up a payment plan to resolve your outstanding balance. You may pay your bill with a check, money order, cash, or credit card. We also accept payments online.

Payment plans for balances after insurance can be made through our Customer Service department Monday - Friday, 9:00 am to 4:00 pm EST at 301-572-3542 or toll free at 800-787-0021.

Why do I receive a statement before the insurance has paid its portion?

As Children’s claims are submitted, you will receive a statement to let you know the charges have been submitted to your insurance company. Once your insurance company has paid the bill, you will receive a bill indicating the remaining balance that is due from you. Please let customer service know if there are any errors in the information on the statement.

Why are my out-of-pocket expenses based on my outpatient benefits?

Our physicians are employed by the hospital, so when we submit claims for their services they are designated as “Outpatient Hospital” (even for our Regional Outpatient Centers) rather than “Physician Office.” As a result, your plan may apply the charges to your outpatient deductible or co-insurance rather than the office visit co-pay.